Gastrointestinal Disorders Flashcards
What is Inflammatory Bowel Disease (IBD)?
What is the Age of Onset?
- Idiopathic, chronic, relapsing and remitting inflammation of the GIT (periods of active disease and dormant disease)
- Age of onset: in the 20s
What is IBS?
2 or more of what criteria?
- Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with 2 or more of the following criteria:
- Related to defecation
- Associated with a change in the frequency of stool
- Associated with a change in the form (appearance) of stool
Should patients worry about the symptoms of IBS?
- Patients are often troubled by these symptoms but they do not lead to more serious outcomes
- Therefore, don’t necessarily require treatment
What are Alarm Symptoms that a patient might describe in GID?
- Blood in stools
- Unexplained weight loss
- Fever
- Severe abdominal pain
What are the 2 Categories of IBD?
- Crohn’s Disease
- Ulcerative Colitis
For Crohn’s and Ulcerative Colitis, what is the site of disease and pattern of inflammation?
- Site of Disease
- CD: Anywhere in GIT (from mouth to anus)
- UC: Colon only
- Pattern of Inflammation
- CD: Patchy – parts of bowel involved, some not involved (discontinuous)
- UC: Begins at rectum, then ascends up colon (continuous)
For Crohn’s and Ulcerative Colitis, what are the symptoms?
- CD:
- Symptoms are more heterogenous due to variation in disease location/extent
- Abdominal pain, diarrhoea (can be bloody), weight loss (including nutritional deficiencies, malabsorption)
- Systemic symptoms of malaise, anorexia or fever are more common than in UC
- Intestinal obstruction due to strictures, fistulae or abscesses
- Might have extraintestinal symptoms (skin, eyes, joints, blood clots) à require management
- UC:
- Significant bloody diarrhoea, may become anaemic
- Urgency as disease progresses
- Abdominal pain/discomfort could be due to constipation or loading or may represent toxic megacolon during severe flares
What are the types of test that are conducted when diagnosing a patient with IBD?
- Faecal Calpro
- Performed on the stool sample
- Measures protein that’s released from neutrophils = marker of inflammation of GIT
- Colonoscopy/Sigmoidoscopy
- MRI/CT/Ultrasound
What are the scoring tools used to assess the severity of UC and CD?
- Crohn’s Disease
- Harvey Bradshaw Index
- Crohn’s Disease Activity Index
- Ulcerative Colitis
- Mayo Score
What are the Goals of IBD Treatment?
- Treat acute disease
- Reduce or control intestinal inflammation and if possible heal the mucosa
- Eliminate symptoms (abdominal pain, diarrhoea, rectal bleeding)
- Prevent complications, hospitalisation and surgery
- Improve and maintain the patient’s general wellbeing
- Decrease the frequency and severity of recurrences of the disease
- Maintain steroid-free remissions and decrease reliance on steroids
- Correct nutritional deficiencies
- Reduce or control intestinal inflammation and if possible heal the mucosa
The medical management of IBD is determined by what?
- Location of inflammation within the GIT
- Degree of involvement
- Severity of symptoms
- Extra-intestinal complications
- Response or lack of response to previous treatment
What are the 2 Phases of IBD treatment?
- Induction Phases (get under control)
- Maintenance Phases (prevent relapse)
- Patients may relapse when in maintenance
Describe the potential use of allopurinol in patients taking azathioprine to manage hepatotoxicity
- Azathioprine has a risk of hepatotoxicity
- The hepatotoxicity is caused by 6-MMP (if high levels, risk of developing hepatotoxicity)
- Concentration of 6-MMP concentration is reduced by using allopurinol
- 6-TGN = active metabolites (how the drug works)
- If you use allopurinol, you block Xanthine Oxidase and therefore 6-TGN concentration increased by using allopurinol
- Using allopurinol with azathioprine is based upon adjustment of the azathioprine dose, to ensure that the 6TGN concentration remains in the right range (Target Concentration)
TDM is increasingly being used to improve the use of the biologics, particularly infliximab. What is it useful for?
- TDM helpful in guiding some of the decision making – try to assess if someone is losing response and what is the reason for this?
TDM: If good concentrations of infliximab and no anti-drug antibodies?
- Tells us drug isn’t working anymore. For whatever reason, the disease is being driven by a pathway independent of TNFa
- There’s enough drug in the system for it to be working, and there’s no anti-drug antibodies to stop it from working à can switch from infliximab to vedolizumab (targets different pathway, no point swapping to adalimumab as it just targets TNFa
TDM: If low concentrations of infliximab WITH anti-drug antibodies?
- No point increasing the dose
- Switch from infliximab to adalimumab, because the immune system won’t recognise adalimumab
TDM: If low concentrations of infliximab WITHOUT anti-drug antibodies?
- Increase dose (either mg/kg or shortening interval from 8wks to 6wks)
Is each individual treatment the same in UC?
- Treatment can vary between patients because treatment is different depending on where in the intestine it is
Describe the importance of drug formulation to the management of IBD both in terms of topical treatments and oral
- Enemas:
- Foams:
- Suppositories:
- Oral Products:
- Formulation depends on which location of the GIT is involved
- Enemas: reaches up much higher – distal colitis
- Foams: sprayed in and penetrate up – distal colitis
- Suppositories: deliver agent to area – proctitis (lower end of rectum)
- If upper part of GIT, rectal products won’t reach = oral products
Describe the importance of drug formulation to the management of IBD both in terms of topical treatments and oral
- Oral Mesalazine Formulations
- Mezavant XL (multimatrix system)
- Pentasa (ethylcellulose-coated microgranules)
- Salofalk (Eudragit-L coated tablets)
- Mezavant XL (multimatrix system)
- Doesn’t release until certain pH and slowly releases its contents over time
- Pentasa (ethylcellulose-coated microgranules)
- CR formulation gradually release mesalazine over time
- Salofalk (Eudragit-L coated tablets)
- EC. Released at pH > 6 once it transitions through the stomach into intestine. Once pH reaches 6, it dumps its dose
What may some IBD patients require?
- Some IBD patients will require bowel resection and may have a colostomy/ileostomy
What are 2 Potential Complications of Colostomy/Ileostomy?
- High volume liquid stoma output
- Short bowel syndrome
Complications of Colostomy/Ileostomy: What can High Volume Liquid Stoma Output result in and how is it managed? Who may play a role in this?
- Can result in leakage or metabolic disturbances
- Managed with high dose loperamide
- Titrated to effect but may be up to 24mg qid
- Some use of codeine and some patients require octreotide
- Titrated to effect but may be up to 24mg qid
- Dietician role in oral fluid and dietary intake as patient is losing a lot of nutrients
Complications of Colostomy/Ileostomy: What does Short Bowel Syndrome Depend on and what is there a potential for?
- Depends upon how much bowel is removed and from where
- Potential for poor absorption of medicines and nutrients
- Preference for dispersible formulations and liquids
- Tablets may need to be crushed
- Preference for dispersible formulations and liquids
What can IBD cause (think blood)?
How is this managed?
What is the treatment?
- Anaemia common in IBD. Caused by iron deficiency and chronic inflammation
- Chronic blood loss, inadequate nutrient intake or absorption
- At least an annual haemoglobin check
- As there is inflammation, ferritin alone isn’t reliable
- Transferrin saturation
- CRP
- Treatment may be with oral iron if tolerated or IV (oral iron ferrous sulphate 200mg up to bd)
- IV preferred when
- Iron deficiency is severe
- Significant anaemia is present
- Active inflammation is present
- IV preferred when
Are the treatments for IBD safe in pregnancy and breast feeding?
- Most agents safe in pregnancy and breastfeeding
- Allopurinol – safety uncertain in pregnancy
- Vedolizumab – limited data but likely to be safe in pregnancy and breastfeeding
Azathioprine in IBD in Pregnancy
- What is there concern for?
- Congenital abnormalities?
- Prematurity?
- Lower birth weight?
- Maybe some concern for neonatal anaemia
- Monitor blood count and baby
- Incidence of congenital abnormalities after in utero exposure to thiopurines
- Relatively safe in pregnancy
- Won’t significantly cause malformations
- Incidence of prematurity (37 weeks’ gestation) after in utero exposure to thiopurines
- More likely to have premature baby
- Incidence of low birth weight after in utero exposure to thiopurines
- Yes, lower birth weight
Biologics in IBD pregnancy
- What is there a risk for?
- To the antibodies transfer to the baby?
- Potentially increased risk of infection in the baby
- Antibodies do transfer to baby via FcRn, however, process isn’t really occurring early on (during high risk period) and therefore baby is exposed. Increased infection risk
- These drugs have long half-lives, the risk of infection is going to persist for some time after the baby is born
What are the Subtypes of IBS?
- Classified into four subtypes based on the patient’s reported predominant bowel habit on days with abnormal bowel movements
- IBS with predominant constipation
- IBS with predominant diarrhoea
- IBS with mixed bowel habits
- IBS unsubtyped
Describe the different treatments in IBS
What about for abdominal pain?
- Dietary modification
- Increased fibre
- Low FODMAP
- Laxatives: may cause cramping and pain
- Loperamide
- Abdominal pain
- Peppermint oil capsules
- Studies shown that it does help reduce abdominal pain and general improvement
- Hyoscine butylbromide
- Mebeverine
- Iberogast
- Evidence to show it is helpful
- Peppermint oil capsules
What are the 2 most important risk factors in PUD and upper GI bleeding?
- H. Pylori and NSAIDs are the two most important risk factors in PUD and upper GI bleeding
PUD:
In patients presenting with upper GI symptoms, choice between what treatments and tests?
- Empirical therapy
- Usually with acid suppression therapy for possible GORD
- Urea breath test
- Endoscopy
- Particularly if
- Alarm symptoms:
- Anaemia, dysphagia or odynophagia, haematemesis and/or melaena, vomiting, weight loss
- Alarm symptoms:
- Particularly if
Describe the importance of timing of a repeat h pylori breath test with regards to cessation of antibiotics and PPIs
- Confirmation of Eradication
- Post-treatment testing is best done with a urea breath test
- To minimise the chance of false-negative results
- At least 4 weeks after stopping abx and bismuth
- PPI therapy should be withheld for at least 1 week (preferably 2 weeks) so you don’t get a false negative
- To minimise the chance of false-negative results
- Post-treatment testing is best done with a urea breath test
What is Diverticulitis?
- Outpouchings in wall of GIT become inflamed and can rupture and release intestinal contents into sterile abdominal cavity = significant medical emergency
